UterineUterine SarcomaSarcoma ChapterChapter 55 FredFred UeUelland,and, MMDD Division of Gynecologic Oncology University of Kentucky UniveUniverrsitysity ofof KentuKentucckyky AnnualAnnual NewNew CancersCancers 140 128 120 100 Uterus 84 82 Ovary 80 Cervix 60 Vulva 42 40 Other 20 13 0 UniveUniverrsitysity ofof KentuKentucckyky AnnualAnnual RecurrentRecurrent CancersCancers 20 20 17 15 15 Uterus 10 Ovary 10 Cervix Other 5 0 OveOverrviewview 33--5%5% ofof allall uterineuterine mmalignancialignancieess 22 perper 100,000100,000 wwoomemenn inin UUSSAA AriseArise frfromom endendoommetrialetrial ssttrromaoma,, glaglanndsds oror uterineuterine mmuscusclle.e. OOttherher memesencsenchymahymall tutumormorss areare rararree 2020 yearyearss afterafter pelpelvvicic radiotheraradiotherappyy BlackBlack wwomeomenn mmoorree ccoommmmonon ClassifClassifiicaticatioonn OberOber,, 19591959 HHoomologousmologous – Pure Stromal sarcoma (endolymphatic stromal myosis) Leiomyosarcom Angiosarcoma Fibrosarcoma – Mixed Carcinosarcoma ClassifClassifiicaticatioonn OberOber,, 19591959 HeterologousHeterologous – Pure Rhabdomyosarcom Chondrosarcoma Osteosarcoma Liposarcoma – Mixed Mixed mullerian tumor (MMT) ClassifClassifiicaticatioonn SGOSGO EndEndoorsedrsed LeiLeiomomyoyossarcarcoommaa EndEndoomemettrialrial StrStromomalal SaSarrccomomaa MixedMixed hhoomologousmologous MullerMulleriianan SaSarrcocomamass ((cacarrcinosarccinosarcomaoma)) MixedMixed heterologousheterologous MullerMulleriianan SaSarrcocomamass (m(mixedixed mmesodeesodermrmalal sasarrccomaoma)) OtherOther uterinuterinee sasarrcocomamass LeLeiiomyosomyosaarcomarcoma MetastaticMetastatic PotePotenntialtial Mitoses Atypia Diagnosis Metastatic 1-4 Any Myoma Very low 5-9 None Myoma with high mitotic Very low activity 5-9 Gr 1 Smooth muscle tumor of Low uncertain malignant potential 5-9 Gr 2,3 LMS Moderate ≥10 Gr 1 LMS High ≥ 10 Gr 2,3 LMS Very high UterineUterine SSaarrcocomama Endometrial stromal sarcoma – Age 45 – Ifosfamide Leiomyosarcoma – Age 55 – Adriamycin/Ifosfamide – Gemcitabine/Taxotere (GOG #131-G) Mixed mullerian tumor – Age 65 – Ifosfamide v. Ifos/Taxol (GOG #161) – Carbo/Taxol (GOG #232-B) UterineUterine SarcomaSarcoma EndometriaEndometriall CancerCancer RiskRisk FactorsFactors Anovulation-PCO Early menarche Exogenous estrogen Late menopause Endogenous estrogen Diabetes Family history Hypertension Nulliparity Granulosa cell tumors Age History of breast of Infertility colon cancer Tamoxifen Menstrual irregularities EndometrialEndometrial CaCanncercer RelativeRelative RisRiskk ObesityObesity (20-50 lb) 33 ObesityObesity (>50 lb) 1010 NulliparityNulliparity 22--33 LateLate mmenopauseenopause 2.42.4 DiabeteDiabetess memellitusllitus 2.82.8 TTamamoxifenoxifen 7.57.5 UnopposedUnopposed ERTERT 9.59.5 PresentationPresentation PostmenoPostmenoppausalausal BleedBleediingng Etiologic Factor Lahey Clinic (%) Mayo Clinic (%) ERT 27 27 Atrophy 23 20 Cancer 19.5 18 EAC 13 16 Cervix 4 1 Other 2.5 1 Atrophic vaginitis 10 9 Endometrial polyps 7 23 Cervical polyps 6.5 14 EndometriaEndometriall CancerCancer withwith PMBPMB Age Total cases Total # EAC % Cancer <50 34 0 0 50-59 161 15 9.3 60-69 92 15 16.3 70-79 43 12 27.9 >80 5 3 60 AtypicalAtypical EnEnddometrialometrial CellsCells EndometriaEndometriall CellsCells onon PapPap PostPostmenomenoppauaussalal Cells Total Hyperplasia Polyps Cancer Normal 74 9 1 1 (1%) + Atypical 22 0 1 5 (23%) Malignant 31 1 0 23 (74%) * +Ovarian cancer *2 cervical, 1 breast, 1 ovary, 19 endometrial cancers HormonesHormones aandnd EndometriaEndometriall CancerCancer HistopathologyHistopathology LeiomyosaLeiomyosarrcomacoma LeiomyosaLeiomyosarrcomacoma Bizarre nuclei LeiomyosaLeiomyosarrcomacoma UterineUterine SarcomaSarcoma UterineUterine SarcomaSarcoma UterineUterine SarcomaSarcoma LeiomysarLeiomysarccomaoma EndometrialEndometrial CaCanncercer HistologyHistology Histopathology Frequency Survival Endometrioid 66% 88% Adenoacanthoma 16% 91% Adenosquamous 5% 62% Papillary serous 8% 63% Clear cell 3% 43% Secretory 2% 89% SurvivalSurvival UterineUterine CaCanncercer StagingStaging anandd PrognosisPrognosis UterineUterine SSaarrcocomama FiveFive YearYear SurvivalSurvival (%)(%) StagStagee II SStatagege IIIIII ESSESS 9898 3838 LMSLMS 5050 88 MMTMMT 5050 <10<10 UterineUterine SSaarrcocomama %% FiveFive YeYeaarr SuSurrvivavivall Stage I Stage III ESS 98 38 LMS 50 8 MMT 50 <10 EndometrialEndometrial CaCanncercer % Distribution % Survival StageStage II 7733 8686 StageStage IIII 1122 6666 StageStage IIIIII 1122 4444 StageStage IIVV 33 1616 Petterson F, ed: Annual report on treatment Gyn Ca, vol 22; Stockholm, 1994, FIGO EndometrialEndometrial CaCanncercer FiveFive yearyear survival,survival, %% 86 90 80 70 66 60 Stage 1 50 44 Stage 2 40 Stage 3 30 Stage 4 16 20 10 0 EndometrialEndometrial CaCanncercer PrognosisPrognosis StageStage ((II--IV)IV) DepthDepth ofof invasioninvasion (A,B,(A,B,CC)) HistologicHistologic didiffferentiationferentiation (grade(grade 1,2,1,2,33)) HistologicHistologic cellcell ttypeype LLyymphvasculmphvasculaarr ssppaceace invasioninvasion PelvicPelvic ccytologyytology EndometrialEndometrial CaCanncercer ClinicalClinical StaStagging,ing, FIFIGGOO 19711971 Stage I Confined to corpus IA Sounds to ≤ 8cm IB Sounds to > 8cm Stage II Cervical involvement ECC, cervical biopsy, gross involvement Stage III Beyond uterus, confined to pelvis Stage IVA Bladder or rectal mucosa Stage IVB Extrapelvic metastasis EndometrialEndometrial CaCanncercer SurgicalSurgical StagingStaging,, 19881988 TotalTotal hysthysteerectrectomomy,y, bilabilatteraerall salpingosalpingo-- oopoophhorectorectomomyy PelvicPelvic washingwashing PelvicPelvic andand parparaa--aaoorticrtic lymlymphph nodenode ssamamplingpling OmOmententeectctomyomy,, upperupper abdabdomominalinal biopsiesbiopsies andand washingswashings forfor serousserous histologyhistology SurgSurgiicalcal RReeccommendatiommendationonss GGOOGG Manual,Manual, 19971997 PrognosticPrognostic notnot therapeutictherapeutic RRememovaloval ofof allall sususspiciouspicious nodesnodes RRememovaloval ofof oneone--halfhalf ofof pelvicpelvic nnoodesdes PAPA nodesnodes frfromom inferiorinferior mmesentesenteericric aarrterteryy toto ccoommmmonon iliiliaac,c, whwheenn indicatedindicated RecRecoommmemendednded forfor >> 50%50% invasioninvasion oror gradegrade 33 lesionslesions So,So, WhenWhen DDoo II DoDo thethe NNodes?odes? Balance between morbidity and utility – Lymphadenectomy is not risk free Preoperative grade – Accurate in 85% of cases Intraoperative evaluation – Frozen section 90% accurate for MM invasion Ueland’s “counsel” – IA gr 1,2 and IB gr 1 insufficient nodal risk to justify additional expense and morbidity EndometrialEndometrial CaCanncercer StageStage II StageStage II ConfConfiinedned toto uterusuterus IIAA LLimimitedited toto endendomeometritriuumm IBIB InnerInner ½½ mmyyoommetretriuiumm ICIC OuterOuter ½½ mmyyoommeettrriuiumm FiveFive yearyear susurrvivalvival (%)(%) StageStage II 88 90 78 80 67 70 60 IA 50 IB 40 IC 30 20 10 0 DifferentiationDifferentiation andand DepDeptthh Grade 1 Grade 2 Grade 3 IA 24 11 11 88% IB 53 45 35 88% IC 10 20 42 UterineUterine SarcomaSarcoma SurvivalSurvival 5-year survival Stage Cell Type S S+R R I MMS 52 % 48 % 29 % LMS 58 % 75 % 33 % ESS 47 % 88 % 50 % II-IV MMS 5 % 16 % 0 % LMS 0 % 13 % 0 % ESS 0 % 33 % 0 % UterineUterine SarcomaSarcoma %% SiteSite ofof RecurRecurrrenceence MMT-Ho MMT-He LMS N=165 N=134 N=57 Pelvis 9 12 7 Distant 33 46 56 None 58 42 37 LymphLymph NoNoddee MetastaMetastasseses ((%)%) EarEarllyy StageStage UterUteriinene SarcomaSarcoma Major, Cancer 1993 20 20 18 16 16 14 12 10 8 6 4 4 2 0 MMT MMT MMT MMT LMS Homo Hetero PelvicPelvic NNoodede MetastaMetastasseses ((%)%) StageStage II 18 18 16 14 12 Grade 1 9 10 Grade 2 8 Grade 3 6 3 4 2 0 FiveFive yearyear susurrvivalvival (%)(%) StageStage II 94 95 90 88 Grade 1 85 Grade 2 79 80 Grade 3 75 70 EndometrialEndometrial CaCanncercer StageStage IIII StageStage IIII CervicalCervical involvinvolveemmentent IIIIAA EndocervicalEndocervical glaglanndsds IIIIBB CervicalCervical strstromomaa EndometrialEndometrial CaCanncercer StageStage IIIIII StageStage IIIIII ExtraExtra--uterineuterine didisseeaasese IIIIIIAA Serosa,Serosa, adnexa,adnexa, ((++)) ccytologyytology IIIIIIBB VaginalVaginal memetastasttasaseess IIIIIICC LLyymphmph nodenode mmetaetasstasestases EndometrialEndometrial CaCanncercer StageStage IVIV StageStage IIVV Regional,Regional, distantdistant memetastasttasesases IVIVAA BowelBowel oror bladderbladder mumucosacosa IVIVBB DistantDistant memetastasttaseasess TreatmentTreatment PrimaryPrimary TrTreeatmentatment SurgerySurgery RadiotherapyRadiotherapy – Medically inoperable – 15% survival decrement each stage HoHormrmoneone thetherrapyapy – Only for grade 1 tumors in young women – Dilatation and curettage Confined to Uterus Extra-uterine disease Surgical staging Resection if possible (Omit LN if extrauterine ds) Stage I,II ESS Stage I,II other Stage IIIC, IV Stage III ESS Stage IIIA,B other No further therapy Whole pelvic XRT XRT (+ Hormone Tx for ESS) +/- Chemotherapy +/- Hormone therapy Recurrence No prior XRT Prior XRT Vaginal Pelvic Extra-pelvic Surgery +/- Chemotherapy +/- Hormone therapy Surgery Whole pelvic XRT WAR XRT +/- Chemotherapy +/- Hormone therapy ChemotherChemotheraapypy NCCNNCCN Guidelines,Guidelines, 20042004 Ifosfamide for carcinosarcoma Doxorubicin for LMS Single agent cisplatin, Taxol, Taxotere, Gemzar Hormone therapy – Megace – Provera – Tamoxifen – GnRH analogs